Provider Demographics
NPI:1134103401
Name:SMITH, LOREN DONNELL (OD)
Entity type:Individual
Prefix:DR
First Name:LOREN
Middle Name:DONNELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11502 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-6522
Mailing Address - Country:US
Mailing Address - Phone:323-756-3937
Mailing Address - Fax:323-756-3938
Practice Address - Street 1:11502 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6522
Practice Address - Country:US
Practice Address - Phone:323-756-3937
Practice Address - Fax:323-756-3938
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07354T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0073540Medicaid
CAU320325Medicare UPIN
CASD0073540Medicaid